Nokea
The nurse assesses a client admitted to the labor and delivery unit and obtains the following data: dark red vaginal bleeding, uterus slightly tense between contractions, BP 110/68, FHR 110 beats/minute, cervix 1 cm dilated and uneffaced. Based on these assessment findings, what intervention should the nurse implement?
- A. Insert an internal fetal monitor
- B. Assess for cervical changes q1h
- C. Monitor bleeding from IV sites
- D. Perform Leopold's maneuvers
Correct Answer: C
Rationale: Monitoring bleeding from peripheral sites (C) is the priority intervention. This client is presenting with signs of placental abruption. Disseminated intravascular coagulation (DIC) is a complication of placental abruption, characterized by abnormal bleeding.
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A client at 32-weeks gestation is admitted to the labor and delivery unit with complaints of severe headache, visual disturbances, and epigastric pain. The client's blood pressure is 150/100 mm Hg. What condition should the nurse suspect?
- A. Gestational hypertension.
- B. Preeclampsia.
- C. Eclampsia.
- D. Chronic hypertension.
Correct Answer: B
Rationale: Preeclampsia is characterized by hypertension, proteinuria, and symptoms such as headache, visual disturbances, and epigastric pain.
At the present time, which agency governs surrogate parenting?
- A. State law
- B. Federal law
- C. Individual court decision
- D. Protective child services
Correct Answer: C
Rationale: Surrogacy cases are decided individually in court, as there is no overarching state or federal law governing surrogacy.
The nurse is conducting a prenatal nutrition education class for a group of nursing students. Which statement best describes the condition known as pica?
- A. Iron-deficiency anemia
- B. Intolerance to milk products
- C. Ingestion of nonfood substances
- D. Episodes of anorexia and vomiting
Correct Answer: C
Rationale: The correct answer is C: Ingestion of nonfood substances. Pica is a condition where individuals have a persistent craving to eat items that are not considered food, such as dirt, clay, or ice. This behavior can be seen in pregnant women due to nutritional deficiencies or psychological factors. Choices A, B, and D are incorrect because they do not accurately describe pica. Iron-deficiency anemia (A) is a condition related to low iron levels in the blood, intolerance to milk products (B) is a lactose intolerance issue, and episodes of anorexia and vomiting (D) are symptoms of eating disorders, not pica.
A 35-year-old primigravida client with severe preeclampsia is receiving magnesium sulfate via continuous IV infusion. Which assessment data indicates to the nurse that the client is experiencing magnesium sulfate toxicity?
- A. Deep tendon reflexes 2+
- B. Blood pressure 140/90
- C. Respiratory rate 18/minute
- D. Urine output 90 ml/4 hours
Correct Answer: D
Rationale: Urine outputs of less than 100 ml/4 hours (D), absent DTRs, and a respiratory rate of less than 12 breaths/minute are cardinal signs of magnesium sulfate toxicity.
A pregnant client with mitral stenosis Class III is prescribed complete bedrest. The client asks the nurse, 'Why must I stay in bed all the time?' Which response is best for the nurse to provide this client?
- A. Complete bedrest decreases oxygen needs and demands on the heart muscle tissue.
- B. You have a small opening in your heart and complete bedrest will help it get bigger.
- C. We want your baby to be healthy, and this is the only way we can make sure that will happen.
- D. Labor is difficult, and you need to save your energy so you will be strong enough then.
Correct Answer: A
Rationale: Complete bedrest decreases oxygen needs and demands on the heart muscle tissue, which is crucial for clients with mitral stenosis.